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Thread: Breaking News in the Great Glasses Court Case

  1. #26
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    Quote Originally Posted by mike.elmes View Post
    It has more to do with the Physicians scope of practice guidelines within the health professions act. Ophthalmologists are not allowed to do remote refractions is my understanding of the situation in Ontario. Secondarily, Ontario's College of Opticians has not expanded its scope of practice to include refracting, as is the case in Alberta. I'm not sure what the status is in BC.
    Yes, I am aware that the authority to delegate the controlled act lies with the individual physician, however I'm wondering why the college of opticians takes no stance on members that are involved in the off-site delegation of "eye tests" but strongly objects to delegation of dispensing - even when an RO is on-site. Here's an honest question open for discussion; what carries with it a great potiential for harm, refraction and prescribing of eyewear in the absence of non-refractive data, or dispensing?

    Do you know of any source outling ophthalmology's ban on remote refraction? I suppose it would be against the interests of most ophthalmologists to delegate refraction - many do own dispensaries.

    From what I've seen in Ontario, opticals that offer "sight-tests" do so with the authorization of a variety of non-ophthal. MD's (ER Physician, Physcial Med &Rehab). The question that arises in my mind then is whether these physicans are adequately trained to prescibe for refractive error? Sure an ER doc sees plenty of eye trauma, and acute disorder, but do they really know what they are doing when they rubber stamp the Rx?

    Also, I think there may be a question of whether the Ontario MD's that delegate refraction to independent RO's are actually authorized by their college to do so (yes I know the RHPA gives physicians access to 12 of the 13 controlled acts, but they must still abide by college regulations). For example, the terms & conditions of the MD supposedly (does anyone know if she consented to this?) used by Great Glasses says that Dr. Trotter "may practise only in the areas of medicine in which DR. TROTTER is educated and experienced." As someone specializing in Physical Medicine and Rehabilitation I'm not sure she would be "educated and experienced" in ophthalmology, but maybe the college uses the phrase lightly. Any opinions?
    CPSO: Delegation of Controlled Acts
    CPSO: Requirements When Changing Scope of Practice

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    Quote Originally Posted by Oedema View Post
    Here's an honest question open for discussion; what carries with it a great potiential for harm, refraction and prescribing of eyewear in the absence of non-refractive data, or dispensing?
    Neither. Or both. It depends on what you consider harm. What's the worst that can happen? The wrong prescription in your glasses does not constitute direct harm, in my opinion. Furthermore, prescribing without dispensing is like thinking about swearing at an old lady, without actually saying it to her.

    An optician who improperly refracts you for glasses does much less harm than an optometrist who improperly examines your retina.

  3. #28
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    if you dispense an incorrect rx to a child you run the risk of inducing amblyopia.

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    But what harm, in your opinion, exists in dispensing eyewear? If there is little to no harm in prescribing an inappropriate spectacel Rx, why enforce the delegation of dispensing?

    Quote Originally Posted by Caddy View Post
    An optician who improperly refracts you for glasses does much less harm than an optometrist who improperly examines your retina.
    How do you distinguish true refractive error from a drug toxicity or maybe NIDDM in the absence of physical examination of the eye?

    Quote Originally Posted by Caddy View Post
    Furthermore, prescribing without dispensing is like thinking about swearing at an old lady, without actually saying it to her.
    What?

  5. #30
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    We differentiate other possible causes of refractive error the same way you do.

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    Well I wouldn't want to be driving on the road with the person that got the wrong prescription.

    After all this publicity Great Glasses is getting we have had numerous people coming in saying that they recieved the wrong prescription from them. A lady came in with a pair of glasses from there that she thought were wrong. We tested her eyes and found that they were 1.50 diopters weaker then what they should have been. Not only that they had about 2.5 diopters of vertical imbalance. She was stuck with a bill of $700.00 for three pairs of single vision lenses in dollar store quality frames. Initially she asked for a refund but they wouldn't give her that. She then brought the new prescription to GG and they wouldn't even change it for her.
    I have told her that if she wanted to take legal action she should do it not only with Great Glasses but with the College of Opticians for failing to keep the best interest of the public.
    Last edited by DrummerBoy; 12-06-2006 at 03:38 PM.

  7. #32
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    And did you also tell her to sue the judge who issued a court order against Bergez which was ignored? Also, please omit any reference to wholesale prices, it is against posting guidlines.
    Last edited by Dave Nelson; 12-06-2006 at 01:32 PM. Reason: addition.

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    Quote Originally Posted by Dave Nelson View Post
    We differentiate other possible causes of refractive error the same way you do.
    Mr. Nelson,

    What methods do you use to examine the fundus?

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    sarcasm? Your previous questions have been rather thoughtful and with some insight into the issues raised in this thread. I suppose my previous answer was a bit curt, so maybe the sarcasm is deserved.
    You know good and well opticians do not do retinal examinations. You mention possible drug interaction/ toxicity as a possible cause of refractive error, as well as non-insulin dependent diabetes. An eye examination must be about the poorest method in the world to detect diabetes, and a fundus exam to detect type 2 diabetes is a new concept to me. My somewhat limited knowledge of diabetes tells me that in the majority of cases, even incipient diabetic retinopathy is normally seen in those patients who are already aware they have diabetes, and are, or should be, on insulin. Refractive errors caused by pathology are often brought to light only after unusual or unstable refractive changes are noticed. I have seen many cases where an underlying cause of refractive change went unrecognized after a full eye examination, only to be diagnosed later after unusual changes were noted, some by opticians, some by optometrists. I noted, for example, some large hyperopic changes in a 14 year old boy, some time ago, who had just undergone a full eye exam by an optometrist. I referred him, on a priority basis, to his physician with a note of my concerns. That young lad was on insulin within days. I have seen keratoconus and other corneal dystrophies go undiagnosed until unusual refractive changes were noted, and I do not believe the prescribers in all of these cases were incompetent, yet each patient had had a mydriatic fundus examination recently. Clearly, a fundus examination does not detect all, or even most cases where refractive errors or changes have an underlying pathological or toxic causes, and your assertion that opticians are somehow missing a key step in determining an underlying cause for a refractive error is, in my opinion, misplaced.As you are aware, some ocular pathologies are accompanied by a reduction in corrected acuities, and some are not. Optometry has no monopoly on using those, and other tests, to determine the need for referal, often to an ophthalmologist or general pratitioner. In my humble experience, other signs, taken in a broader context,are key to determining underlying causes of refractive errors, such as familial history, best corrected acuities, meds, and other factors, which then may trigger a referal, and very possibly, another fundus examination, and possibly blood sugar testing, which, as you are aware, necessitates yet another referal. I need not make any sarcastic comments about asking how optometrists test blood sugar, any more than your inquiry about how I examine a fundus. I await your inevitable reply.
    respectfully,
    David Nelson
    Last edited by Dave Nelson; 12-06-2006 at 11:28 PM.

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    Mr. Nelson,

    Iím sorry my reply came across as facetious, perhaps I need to explain where Iím coming from here: I am an optometry student (wasnít an option when I signed up for this site) in the US, grew up in Canada, and just have a few genuine inquires. While I realize that the vast majority of ROís do not do retinal exams, there is at least one in Ontario I am aware of, he has a practice with a family practitioner, that routinely picks up the direct oíscope to have a look inside. I guess I was just wonder if thatís what you meant when you stated that opticians make a differential diagnosis in the same way an optometrist does.

    You correctly assert that a fundus exam is not the only component needed to determine a probable etiology for a refractive shift Ė it is but one of many procedures that allows the practitioner to rule out possible diagnoses before prescribing treatment. True, diabetic macular edema may not be very apparent upon inspection, but how will you know unless you look? What if you had a patient present with long standing stable blur, you refract, donít examine the retina, or iris, dispense and miss neovascularization that proliferates and threatens your patients vision?

    A fundus exam in isolation is by no means the sole basis of anyoneís diagnosis of DM, one cannot even make a certain diagnosis based on the results of a blood glucose test. However, a complete eye exam is a very powerful set of procedures, when used collectively will help the astute practitioner find the primary cause of the patientsí complaint. Is it foolproof? No, things do get missed by competent providers, but only by considering all possibilities and ruling them out can you be as sure as one can be that youíre not delaying necessary care. You really donít know what you donít know.

    Speaking of blood glucose; I will admit I am not entirely aware of which provinces may or may not allow ODís to use tests strips and a glucose meter (while technically I donít think this is a controlled act in Ontario?) or order laboratories when indicated, but here in the US ODís routinely test blood glucose in office and order full labs. Nonetheless, a single blood glucose test while often useful is not the basis of a DM diagnosis, multiple readings are necessary, as is a test of glycosylated hemoglobin (HbA1c) which gives an indication of the blood glucose levels over a period of a few months (not just what you ate for breakfast). The difference here is that ODís DO want to know what a patientsí blood glucose state is while Iím concerned that opticians flirting with the idea of prescribing are indifferent to non-refractive data.

    You are correct to note that many progressive anterior segment diseases will not be detected by a fundus exam, however I donít accept this as an argument that a fundus exam need not be performed. An emerging keratoconic, unlike a diabetic, need not be detected at the absolute earliest moment Ė there is no preventative therapy that can be undertaken to help that patient avoid future complications. Sure it would be nice to counsel that patient before the correctable quality of vision is decreased, but RGP / penetrating keratoplasty is not necessary until that time.

    You make mention of numerous other variables such as family hx and medications that you can investigate, and claim mitigate the need for physical examination of the eye. I know I may have chagrined you already with my questions, but just out of curiosity what aspects of family and personal health history do you and other ROís investigate. Do you have a checklist? What are some of the conditions youíre looking out for? Do you screen medications?

    I sincerely hope this does not come across as sarcasm, while I do not agree with the principle of sight testing, I am genuinely interested in learning about the position of opicianry in this regard. Sorry about the ridiculously long reply.

  11. #36
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    While I'm sure Dave will go into this in more detail, the following is the form that the COBC requires patients to sign before undergoing a "sight test"

    I've made my opinions on this clear in the past, I really doubt there's much reason to go into it again other than to say I disagree with the concept.

    Client Notice - Automated Refraction
    Last edited by Ory; 12-07-2006 at 10:01 AM.

  12. #37
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    I apologize for any misunderstanding about your intent. I take no exception to anyone who disagrees with any thing I have to say. One fundamental principle that keeps being overlooked by optometry in the whole refracting optician debate is this: It is not, was not, and will never will be intended to replace a full eye examination, and was, and is, always intended to be performed as a component of complete eye care, including eye exams. Here in B.C, those under 19 and over 65 are excluded from having an optician performed refractin unless they are directly refered by a prescriber. Your claim that I mitigate the need for an eye health examination is untrue: look at every post I haver ever made, and you will never see me suggesting eye exams are unnecessary. Opticians are eyecare professionals, and have always supported the promotion of ocular health. I know full well the need for periodic fundus and IOP checks, and have seen the effects of delayed diagnosis in glaucoma. We have consulted with ophthalmology every step of the way in this matter, have never excluded optometry from the process, and above all, have given every consideration to the one area of utmost importance: the safety and health of the people we serve. Perhaps the time has arrived for optometry to recognize opticians as health professionals who are capable of some clinical judgement, and stop trying to convince each other that optical store clerks are representitive of opticianry as a whole.
    Where are you studying? when do you graduate?
    All the best.

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    there is such a great divide in canada esp. in ontario between OD's and opticians...it just seems ridiculous that opticians can't work directly for an OD...is it because the "good 'ol boys" in the Cdn Optometric Assoc, in particular the Ontario assoc want to keep all glasses confined to OD's...why can't they all be friends..if only the assoc would realize that by letting the OD worry about the exam and eye and not so much about how to get the damn screw in the spring hinge, it would better serve the public..there would be no basis for this nutbar at GG to claim that there is a monopoly on eye exams...if OHIP would recognize the ability of OD's to detect, monitor and treat many pathologies there would not be a 1-2 year wait to see an OMD...rant over...go leafs go

  14. #39
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    Quote Originally Posted by Ory View Post
    While I'm sure Dave will go into this in more detail, the following is the form that the COBC requires patients to sign before undergoing a "sight test"

    I've made my opinions on this clear in the past, I really doubt there's much reason to go into it again other than to say I disagree with the concept.

    Client Notice - Automated Refraction
    The form you show is not the form clients need to sign.

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    interesting diabetic data for Dave

    Dave,

    Please follow this link to read about the numbers of diabetics and pre-diabetics (read as not diabetic by the current definitions of diabetes) that have diabetic retinopathy, either before or at diagnosis of type 2 diabetes. Perhaps a fundus examination may reveal more about diabetes in some cases than blood sugar testing or symptoms.

    http://www.diabetesincontrol.com/mod...ticle&sid=3019

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    I have been following the discussions regarding sight testing, and find the platform of the opticians who advocate sight testing quite alarming.

    As an optometrist I have seen many cases of serious ocular pathology in patients who were asymptomatic and correctable to 20/20. These include glaucoma (~20% of glaucoma patients never have an abnormally high IOP), active toxoplasmosis, melonoma, diabetic retinopathy (several patients were previously undiagnosed and their refraction was similar to the old glasses they brought to the exam), retinal detachments, retinitis pigmentosis, Coat's disease, etc, etc.

    I have also seen patients with previously undiagnosed brain tumours.
    I have seen a patient with Gardner's syndrome.
    Of course many patients with diabetes and HTN.

    In the vast majority of these cases, refraction alone would not have detected the condition.

    The argument that many opticians make is that they DO think an eye exam is important, but only every 5 years...wow.

    When is the last time someone gave you an accurate date of their last exam. Most people underestimate the time since their last exam, so 5 years may really be 7 or 10...who knows.

    I have even seen patients who wear glasses from a sight test who have NEVER had an eye exam.

    The sight testing issue in BC will be resolved politically. It is interesting to note that that Optometry and the College of Physicians and Surgeons in BC do not condone a refraction in the absence of a thourough eye exam. It is also interesting to note that these are the only groups medically educated.

    So sight-testing opticians, go ahead and believe whatever it is you want to believe. I, however, cannot imagine doing a simple refraction and sending my patients out the door....I could not sleep at night.

    Later,

    JP

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    Thanks for the link. Just this morning I read an article in the Vancouver Province newspaper about a breakthrough in identifying at-risk people for glaucoma coming out of Montreal. I lectured on low vision at the Canada West convention this year, and did a short discussion on the primary causes of visual impairment. I did express some surprise during the lecture about the stats on diabetes which I found on the Health Canada website. We can ill afford to ignore or minimize the threat to vision that diabetes and glaucoma present, and any effort to identify risk factors earlier will certainly have the support of all vision care professionals. Is mydriasis essential to an evaluation for diabetic retinopathy, or at least to detect minute changes in retinal vasculature? Can M.D.s be trained to recognize these changes? Thanks again for the link, mapleleafs.

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    Quote Originally Posted by Dave Nelson View Post
    The form you show is not the form clients need to sign.
    Thanks for the correction. I pulled it off the COBC website under the "sight testing" tab. Do you have a copy of the form patients actually do sign? One you could post or link to?

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    Last edited by Refractingoptician.com; 03-02-2007 at 12:49 AM.

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    We need another battle about refraction like we need a hole in the head. As Ory has indicated, everyone seems tired of yet another discussion about optician performed refraction, and starting another thread might be starting another war. The subject is like an alligator pit: put one toe in and suddenly you're dragged in for a bloody fight. Ory, there is a link on the college website for the consent form, but I couldn't get it to work. It may be down since the final document is still being developed. Oedema, good luck on your studies. I would be happy to answer any questions you have about the rather touchy subject of optician-performed refractions, on another thread.
    Stonegoat, listing all the eye disease you have diagnosed is kind of redundant. Thats your job. Thats what eye exams are SUPPOSED to do. You SHOULD have trouble sleeping at night if all you did was a refraction. If I were a doctor and saw a patient for a physical examination and only did a blood pressure measurement, I'd have trouble sleeping at night as well. But if I were a pharmicist and helped an elderly person with a blood pressure measurement, and nothing else, I would sleep fine.
    As far as seeing a person who had had a sight test and never an eye exam, I point to a B.C. optometrist convicted of bilking the medical services plan. Just because one guy does it, does'nt mean all optometrists do.
    Finally, your assertion that the "medically trained" groups in B.C. oppose this initiative, I will leave you with this: the first group to ever suggest opticians seek changes in their scope of practice to include stand-alone refraction was BCEPs: the B.C. Eye Physicians and Surgeons. Yes, thats right. B.C. ophthalmologists put the idea on the table first, and its only fair for me to point out they are indeed "medically trained."

  21. #46
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    Quote Originally Posted by Dave Nelson
    Thats your job. Thats what eye exams are SUPPOSED to do. You SHOULD have trouble sleeping at night if all you did was a refraction.
    You are the man.

    I have been following this thread and reading about the whole GG issue and am honestly ashamed of the guy. He sounds like the one bad apple in a bunch. I hope that he and his organization is crucified to the fullest extent of the law, to hopefully make an example. Good luck to those that want to picket and sue.
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    From what I see the issue is quite basic.
    Optometrists do not want to loose their profits to opticians who are dispensing based on a computer generated script. :finger:

    Opticians however would like to offer residents of Ontario an alternative to a complete eye examination. And as technology progresses these options will become readily accessible, and I think people will demand it. The reasons being:
    1) Why pay for an eye examination, when all one really wants is a new pair of glasses or contact lenses? As an adult, in a democratic society, why should I be forced to pay to see clearly? If I choose to only get a new prescription, then why should anyone object? When did my prescription for sight, become part of an examination for my eye? They are two totally separate things.
    2) Technology is progressing so quickly, the cost and accuracy of autorefractors is going to change everything. And one cannot logically dispute the consistent accuracy of computers. Machines are far more precise when it comes to measurements, and that is exactly what a prescription for vision is- a measurement.

    A great case in point is, should you have to pay for a full physical every time you go to your physician's office? If MDs started lobbying the government for this action, wouldn't everyone stand up against such policy? I am sure even optometrists would complain and argue the validity in such a setup. And even though the doctor might give you medicine for a cold or a cough, they could easily argue that had they done a complete physical they could have attributed those symptoms more precisely to some other underlying physical complication/condition.


    It is a shame that in today's time, we are forced to pay a fee to have crisp vision. Especially when one considers that there is an accurate and free alternative.

    I am a firm believer, that when it comes to one's own body, what ever method they choose to correct their own condition is a freedom of choice every adult human has the right to. To force someone to do otherwise is unjust... doesn't matter what your intentions might be.

    Great forum.... my regards to everyone who has participated.

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    The Ontario optical industry seems all turned around to me. Opticians should be legally allowed to work for Optometrists.....why is that??

    Is this true?

  24. #49
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    Optometrists should not be employed by dispensers for the same reasons physicians should not be located inside pharmacies and employed by pharmacists.

  25. #50
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    "1) Why pay for an eye examination, when all one really wants is a new pair of glasses or contact lenses? As an adult, in a democratic society, why should I be forced to pay to see clearly? If I choose to only get a new prescription, then why should anyone object? When did my prescription for sight, become part of an examination for my eye? They are two totally separate things."

    ---------------

    The recent decision by Justice Crane in the Ontario Superior Court was able see through arguments that a refraction could or should be separated from a complete ocular assessment, a position that is wrongly echoed by some optical retailers.

    Perhaps it's time the government permitted birth control pills to be obtained in vending machines too? Is it really necessary for sexually active women to have PAP smears? Of course not (and I say so sarcastically).... cervical cancer is rare. The problem is that in essence, a patient (or in the case of an optical dispenser... a 'client') "doesn't know what they don't know".

    For a century, the optical professions have tried to move from the back of jewelery stores only to have some try to separate a refraction from a comprehensive assessment and push that 'procedure' to the back of an optical shop. How unfortunate.

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